Claims Quality Auditor

HealthEdge•Remote,

6d•$44,000 - $50,000•Remote

About The Position

UST HealthProof is looking for a Claims Quality Auditor with health plan claims administration operations experience. This role will report to the Lead Auditor or Quality Audit Manager. The Quality Auditor performs audits of an assigned group of transactions (claims, enrollment, premium billing, paper claims and correspondence scanning) and will interact with the client audit team and operational managers daily to report on audit findings, which have an impact on production and quality. This role requires the ability to work both independently with limited supervision and collaboratively in a team environment.

Requirements

High School Diploma or GED required.
3 years health plan claims auditing operations experience required
Proficiency in using MS Suite, specifically Excel, PowerPoint and Outlook
Ability to analyze contractual SLAs and KPIs
Ability to effectively communicate and collaborate with a remote team

Nice To Haves

Medicaid claims auditing experience preferred.
HealthRules Payor or Guiding Care exp preferred.

Responsibilities

Perform audit of transactions processed by health plan administration associates for a specific customer.
Be responsible for following the customer quality process and tools for audit and rebuttal process.
Share QA results with individual associates, coordinate with operational Team Leads and managers to provide feedback to individuals, clearly identifying errors and opportunities of improvement.
Collate, compile and reports both team and individual associates’ QA performance to management and individuals.
Provide inputs to Training team and Team Leads for up-to-date written processing instruction/refresher training needs.
Participate in UST HealthProof’s or the customers’ Audit the Auditor program.
Participate in semi-annual or annual auditor calibration activities.
Maintain currency on CMS claims processing rules and guidelines for Medicare Advantage organizations and ACA Exchange and Off Exchange lines of business.